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P� ��NT <br /> r '"IL PY <br /> 0. ..... C a Joaquin County E� 'IV <br /> ED <br /> A <br /> ' `s� Environmental Health Department SITE j <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95AL 2 4 2008 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgovgkgIJOAd( LlIN COUNTY UNIT IV <br /> ENVIRONMENTAL <br /> Well Permit Application HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made-to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-11153 and the Standards of San Joaquin County Environmental Health Department. <br /> _ Assessors <br /> WELL Location 22€G ' Cit I m' ' Cross Street' P11-IC ' City t-1 Zip 615"Zaq Parcel# CoS� W <br /> PROPERTY Gip 'q�ne#�9 11-7-834'9 <br /> OwnerGtT © `a �K"'�024 Address �0• Erb Pa1Z� Citys'2Y'kTL]tJ zip \ <br /> C-57Contractor F E'�IS3Qt�1 AddressZ%; WIC W4H dt`- City�t c K-Tt7t.lZip ?0� Lic#6'�3g1Phone#/�ZCI)4GQ <br /> 151.4 UM 4rA-T6L0FeC 7"14 Phone#t�llco772�{-�Z <br /> Consultant/Sub Cntrf `ILL ENGr�, _Address CTTQ4 Z2 G E City Lic# i H <br /> GIS Coordinates:X 3 ,Y —12i-2-90 Township Range Section <br /> WORK TO BE PERFORMED: <br /> )KNEW WELL 1 BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> la SOIL BORING# d OVER-BORE. DIAMETER <br /> WELL# M W 1 S _ 13 PRESSURE GROUT <br /> 0*Other /} GROUT SPECIFICATIONS <br /> COMMENTS: t�� . /k.a-+L UKe r L 3Z' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS It <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE S 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DEA: __---_ <br /> �]EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESSS( 414 L40 TYPE OF CASING: 0 STEEL APVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2 Cc:- f TREMIE TYPE TO BE USED: 0 AUGERS *OSE <br /> []AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,WYes 0 No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL`BORING 0 HAND AUGER GROUT SPECIFICATIONS 5'Tv Q 1-t 0 fb- 43L4 Ib 0 C E els <br /> 0 OTHER:_G OTHER APPROX. BORING DEPTH 5;0 A -M�BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED. (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, and Regulations, and all applicable California State Laws. <br /> GG��''// <br /> 61k,11- u�� /!1/��12- 07,>/GG Edl/�i�v��rtjv <br /> Signed x Title/Company <br /> ' Date <br /> ,r IL6 / "7-2 L1, 0 9/ <br /> Print Name�ZV r�I �-f�!-�L y L KL GI--/ <br /> DEPARTMENT <br /> `USE <br /> eONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: !S /- C /n""`� ,�S•2- <br /> WORK PLAN DATED: <br /> Application Accepted By <br /> Date issued Area tJ� <br /> Grout Inspection By Date g-1T'6V _Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> MW 143S-3- E) a ,s�� �/ o�' sR#a q 3 <br /> C-57Z WCC WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc-#— <br /> AZy�7 <br /> EHD 29-02-001 Aw O$'. A L.C/ <br /> 6122/04 J' <br />